Basics on Craving

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Basics on Craving

• Steven D. LaRowe, Ph.D.
• Center for Drug and Alcohol Program
• Medical University of South Carolina
• Substance Abuse Treatment Center
• Ralph H. Johnson VAMC

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Craving Definition

• Merriam-Webster An intense, urgent, or abnormal
  desire or longing.
• My definition Motivation to acquire something
• In recovery, some people are beset with very
  strong cravings. However, a substantial portion
  of people do not experience the intense desire
  or longing.
• Goal in therapy is to recognize what triggers
  craving so that we can purposefully, and with
  forethought, put things in place to manage
  craving when and if it occurs

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But what if they experience no craving?

• People have their own working definitions of
  craving
• I suspect they think of craving as
  uncontrollable urge.
• I suspect that addicts view craving as an
  either/or phenomenon. Either you have it, or you
  dont.
• I think of craving as part of a continuum of
  motivation, with the uncontrollable urge being
  at the most intense end of the spectrum

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(By the way, why WOULDNT they have craving)

• Some dont ever report
• Some are motivated to be better
• Some are in treatment and not in their usual
  environment, so not encountering the same
  triggers
• Some have external inducements (i.e. housing that
  requires being clean, probation, recent crisis)
  that affect motivational state

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Another way to frame craving Wanting, Thinking
About it

• Sometimes, after craving is denied, I will ask
  them if they want to use the drug, or if they
  think about it sometimes they will say yes,
  even if they deny craving
• Treatment-seeking cocaine addicts report higher
  ratings of wanting to use than ratings of
  craving in response to slides depicting cocaine
  and cocaine use (Study by Malcolm et al. in
  progress)

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Continuum of Craving
Uncontrollable Urge!
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Craving doesnt last

• I need to look of an official reference but
  estimates range between 5 to 15 minutes, give or
  take, depending on the source.

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Cues activate the Brain
Study at MUSC, Myrick et al. 2004. Participants
looked at slides, got a taste of alcohol.
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Cues can activate the brain, and you might not
even realize it!!!!

• Childress et al. 2008
• Show slides depicting neutral, aversive, sexual
  content, as well as cocaine
• Show slides 33msec (fast as an eyeblink)
• Scan brain using fMRI

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Activation by Unseen slides

• Unseen (subliminal) cocaine slides activated
  striatum (aka go circuits)

• More response to subliminal cocaine slides
  greater positive response later to supraliminal
  presentations of those slides
• CONCLUSION Your motivational circuits can be
  activated without you even knowing about it!

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What does all this mean?

• An addicts brain is activated by cues, including
  their basic motivational circuitry
• You dont have to be aware of seeing the cues to
  have them activate your brain
• From this, I conclude that motivational processes
  can get started long before we realize it
• In therapy, it is our job to help patients
  uncover what gets their motivational circuits
  going
• They need to monitor cravings to help them
  discover these subtle cues and to prepare a plan
  to help neutralize these cues

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Brain Circuits
STOP Circuit Conscious Awareness WILLPOWER
GO Circuit Non-thinking SURVIVAL SYSTEM
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Cue information is refined through cortical
processing and available for conscious recognition
Cue information fades and is NOT refined by
cortical processing
Cue is NOT consciously recognized. Decision to
acquire is determined by sense of urgency.
Although very quickly presented, unrefined cue
information STILL registered in limbic
area Preparations made to act (acquire)
Unrefined cue information registered in limbic
area Preparations made to act (acquire)
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..And what if they arent craving?

• Lets assume thoughts and memories are
  precursors to craving
• Monitor where those occur this gives us our
  best guess where cravings might occur
• Those are easier to overcome anyway

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What do we do?

• First, teach clients to monitor cravings and
  pre-cravings
• Explain that cravings are elicited by External
  triggers in our surrounding environment (e.g.
  people, places, things)
• Explain that cravings are elicited by Internal
  triggers (e.g. emotions, both positive and
  negative)

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What do we do, page 2

• We need to find out what/when these triggers
  occur
• Once we discover this, we put a plan in place
• For external
• Avoid (plan to avoid those things)
• Distract (keep busy, avoid too much idle time and
  boredom)
• Escape (have a way to get away)
• Endure (cravings dont last, ride it out)
• For internal various emotion management
  strategies cant avoid them, suppression is
  preservation.

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What to do, part 3

• Youve explained the rationale, now collect the
  data!
• Give handout for craving monitoring
• You can use the 0-100 scale to rate cravings.
• 0-25 just a thought
• 25-50 A pleasant memory, reminisce
• 50-75 Wouldnt it be nice, heres how I could
  do it.
• 75-100 You start to act on the plan
• When the person has craving, have them record as
  much detail about the situation as possible
  this helps identify triggers that they might
  otherwise not have noticed
• Use this data to help devise specific plans to
  neutralize these cues (for future sessions)

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Other facts about craving

• People tend to assume that in the future, they
  will feel the same way they do now
• This holds true for craving. People will make
  future predictions of craving based on how much
  they are craving now
• This means if they are not craving now, they will
  underestimate the amount of later craving they
  will experience

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People in treatment will not crave, because
treatment is not their using environment. Craving
can re-awaken when the recovering addict returns
to that using environment.
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Evidence for underprediction

• Article on the Empathy Gap
• Dependent measure was Willingness to Accept
  Craving asks people how much theyd need to
  be paid for them to tolerate craving
• High value craving more strong, need to pay
  more for me to tolerate it
• Low value craving lower, you dont need to pay
  me so much to put up with it

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Underprediction evidence

• People either deprived (hot) or recently smoked
  (cold). Deprived people needed more to accept
  craving
• Predicted their willingness to accept craving
• Result People who just smoked assumed theyd be
  more willing to accept craving than they actually
  did later

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Another issue with Craving Cues can be more
compelling over time

• Incubation of craving
• Train rats to push lever for cocaine
• Pair cue with cocaine
• Stop cocaine infusions ? extinction
• Show cue later, rat presses again reinstatement
  ? mode for relapse
• Depending on how long you wait, cues can elicit
  more reinstatement

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Cues get stronger evidence
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If no coke, rat stops pressing
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The Power of a CUE or TRIGGER

• The light is an animal version of a cue or
  trigger that can cause the return of
  craving/motivation to seek drugs
• Generally, people would expect cues to get weaker
  over time
• Evidence for this goes against what one might
  expect

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CUES can GET STRONGER
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But they reach a peak and weaken
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Caution The drug itself can still activate the
behavior doesnt seem to change
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What this means?

• People in treatment often assume that craving
  wont return and underestimate the future impact
  of craving.
• The impact a craving that takes you by surprise
  has more affect on behavior
• Cue induced craving may get stronger over time,
  but can drop if given enough time
• Why tell patients this? Because patients will
  assume somethings wrong if craving resumes